Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 1001361 DEA: 120M9704 EFIS: 1213000099
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-57-11.5/12.5
Work Description: CONST BRIDGES, RET WALLS, JPCP, HMA, CONC BARRIERS AND ELECT SYSTEMS.
Location Description: ORANGE COUNTY IN ORANGE AND ANAHEIM FROM 0.2 MILE SOUTH OF ORANGEWOOD AVENUE UNDERCROSSING TO KATELLA AVENUE UNDERCROSSING
Contractor Name: ORTIZ ENTERPRISES, INC.
Contractor Address: Unknown
Resident Engineer: Aythem Al-Saleh Structure Rep.: Mohammad Rousta
DIME Sample ID: 2026-03-24-48
TL Number from the TL Form:
Sample Submitted By Organization: OldCastle Precast, Incorporated - Fontana
Sample Organization Contact: (951) 396-0214
Type of Sample: Quality Control
Type of Material: Concrete
Sample Taken Date: 03/24/2026
Date that the sample was received by the laboratory/organization performing the testing: 03/24/2026
The quantity of what the sample constitutes: 9 cylinders
A brief description of the sample: Concrete Cylinders
From where was the sample collected: Fabricator
Laboratory sample identification:
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: OLDCASTLE PRECAST
The concrete mix design number: UV-247B
The truck number from where the sample was collected:
The batch plant ticket number from where the sample was collected: 84964
Concrete batch plant:
The fabricator/manufacturer designation for the sample:
A detailed description of where the material sample was collected: On site next next to the form
Where the material sample would have been placed if not sampled:
From Lot No.:
Bag Lot No.:
